Almost one in three young women ages 15 to 24 years old report having relied on withdrawal in the previous three years.[1] In fact, almost 60% of reproductive-age women report having relied on withdrawal at some point in their lives.[2] Yes, that withdrawal…coitus interruptus, the ancient method of birth control most clinicians thought went the way of homing pigeons and schooners. Not so. Withdrawal is alive in well, in the United States.

Often, women may not acknowledge use of withdrawal because it may be supplemental to another method. A woman may forget to have taken oral contraceptives, or run out of pills, and so fall back to withdrawal as a backup method. If she relies on fertility awareness methods, she may think about using withdrawal during those days designated for abstinence. And if a recent study is any indication, a substantial proportion of men put on condoms after they’ve brought themselves close to ejaculation via penile-vagina intercourse. In that study, 43% of college-age men reported using withdrawal during the initial phases of intercourse, then applying the condom for intravaginal ejaculation.[3] So, can these young couples say that the condom is their method of contraception, or is it really withdrawal?

With the array of more effective contraceptive options, why do couples choose withdrawal? First, it’s a method that’s always available. They can’t “run out” of the method or forget it in their drawer. Second, it’s free, at least up front if you don’t take into account the cost of an unintended pregnancy. In that case, withdrawal becomes one of the more costly of methods. Third, use doesn’t require a physical examination, a visit to a clinic, a discussion with a pharmacist, or an encounter with a cashier. Some couples like that the method involves the male partner.

What difference does the surprisingly high use of withdrawal make to your clinical approach? A lot, actually. With a typical failure rate of 22%, withdrawal falls into the last tier of efficacy. The perfect use failure rate is a reputable 4%, but the quality of use is not under control of the woman at risk, and perfect use can be jeopardized by immediate conditions. Is he under the influence of drugs or alcohol? Can he be counted on to have control over his ejaculation and his withdrawal from the vagina? After all, impending orgasm is a powerful force that can overcome intention for the man or the woman.

What might be your role? Ask directly whether she ever uses withdrawal, even if she uses another method. Take the time to remind her that the method can have a high failure rate. Some couples are at greater risk than others because just over 40% of men have sperm in their pre-ejaculate emission.[4] These men generally do not know that they release sperm then. The amount runs only to about 20 million, so the risk is low, but these sperm are motile. And, as you know. Couples using withdrawal are still at risk for sexually transmitted infections.

Contraceptive Technology

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This month’s clinical pearl

December 2018 Clinical Fact:

“Because implants and IUDs are highly effective, they are excellent choices for the short-term, too, and the fact that an implant or an IUD is good for “up to” 3 to 20 years is an added advantage but not always relevant.” — Contraceptive Technology, 21st edition